Quiz 22

It is a rainy day in early September. You are working in a small town approximately 45 minutes west of a large urban area. You have a small primary care hospital in your community. You are an advanced care paramedic and are working with someone who has equal training. You are dispatched to a local industrial site for a 35-year-old male patient that has fallen 35 feet from a platform he was working on.

On arrival, you find a male patient lying supine on the ground with a group of bystanders standing around and a first aider holding C-spine. You were informed that the patient was welding a pipe end on a pipe that had water at 2800 psi behind it when the plate shot off, striking the patient in the chest and throwing him from the platform. The patient was wearing a hard hat and coveralls, but had no other safety gear on. Bystanders inform you that the patient was initially unresponsive to any type of communication but has since awakened. The patient is confused about events, place or time.

As you approach your patient, you notice that he is soaked with water, and that his hard hat has been removed. The bystanders have removed his coveralls from the left side of his chest and you note a large bruise. On your preliminary examination, the patient appears to have an angulated fracture to the left lower leg. While talking with the patient you note he is awake and alert but confused as to the events and continually asks the same questions about the events over and over. He states he has no feeling in his lower extremities and some numbness and tingling in the upper extremities.

On further examination, you note the patient has no sensation or movement of his body from the nipple line down. He complains of pain to the left side of his chest but due to the decreased sensation is unable to properly describe and rate the pain well. He also complains of shortness of breath. The patient’s pelvis is stable.

The vital signs come back from your partner:

• HR: 62

• RR: 32

• BP: 84/44

• SPO2: 89%

• BGL: 6.4mmol/l

• Cardiac monitor: sinus rhythm with noticeable ST segment elevation in lead II

1. This patient’s condition should be labeled as _____________ and the transport decision should be a _____________ and _____________.
   A) stable, stay and stabilize
   B) unstable, load and go
   C) stable, load and go
   D) unstable, stay and stabilize
2. The patient’s respiratory rate and oxygen saturations show a significant shortness of breath. What is the proper treatment for this patient?
   A) Nasal cannula at 3 LPM.
   B) Non-rebreather at 10 LPM.
   C) Non-rebreather at 15 LPM.
   D) BVM assisted ventilations at 15 LPM.
3. The proper way to move this patient should be:
   A) long spine board with C-spine precautions.
   B) scoop stretcher.
   C) ambulate to the stretcher.
   D) KED.
4. If the patient in this condition was more tachycardic you would expect him to have _____________.
   A) hypovolemia
   B) sepsis
   C) neurogenic shock
   D) anxiety
   E) A and C
5. The slower normal sinus rhythm is a sign of what underlying condition?
   A) Hypovolemia.
   B) Sepsis.
   C) Neurogenic shock.
   D) Anxiety.
   E) A and C.
6. You discover paradoxical motions to the left side of the chest while doing a rapid trauma survey on this patient. What condition is this a likely sign of?
   A) Pneumothorax.
   B) Hemothroax.
   C) Flail segment from rib fractures.
   D) Sucking chest wound.
7. The proper treatment for the above condition at a BLS level is:
   A) occlusive dressing.
   B) manual support followed by securing the segment to the surrounding chest wall.
   C) positive pressure ventilation.
   D) nothing: the injury will correct itself.
8. Failure to splint a flail segment causes:
   A) hypoxia.
   B) ineffective ventilations.
   C) decreased pulmonary.
   D) all of the above.
9. This patient is hypotensive and requires an intervention to be initiated for treatment. What type of intervention should be initiated and when should this skill be done?
   A) Large bore IV of NS; done before leaving the scene with the patient.
   B) Small bore IV of NS; done before leaving the scene.
   C) 2 large bore IVs of normal saline or Ringers lactate, done en route to the hospital with this patient as well as placing the patient in the Trendelenburg position if possible.
   D) Transporting the patient to hospital in the Trendelenburg position.
10. The decision to transport the patient to a regional trauma centre would be initially because of the:
    A) MOI.
    B) ABC complications.
    C) LOC complications.
    D) all of the above.
11. The optimal scene time for this patient would be less than:
    A) 25 minutes.
    B) 10 minutes.
    C) 30 minutes.
    D) 1 hour.
12. The primary cause for the patient to stop breathing would be from:
    A) hypoxia.
    B) decreased LOC.
    C) head injury.
    D) all of the above.
13. The fast respiratory rate can be from:
    A) ineffective ventilation.
    B) hypoxia.
    C) high spinal cord shock.
    D) all of the above.
14. The patient was soaked in water on your arrival. The best way to reverse the hypothermia would be to:
    A) cut off all his clothes immediately on scene.
    B) place him in the unit and then cut off his clothes and apply heat from your ambulance to maintain normothermic.
    C) leave the clothes on until he is received in the trauma centre.
    D) apply the heater to him en route without removing any clothes.
15. The best way to splint the leg fracture would be to use a:
    A) traction splint.
    B) inverted KED.
    C) pillow splint.
    D) air splint.
16. The primary role of the paramedic for this patient would be to:
    A) maintain an adequate airway.
    B) perform an advanced airway procedure.
    C) assist to maintain adequate central and peripheral perfusion.
    D) A and C only.
    E) all of the above.
17. The optimal BP in this patient would be:
    A) 100 to 110 systolic.
    B) 60 to 70 systolic.
    C) 70 to 90 systolic.
18. The paramedic can administer intravenous fluid but the BP might not be responsive due to:
    A) hypoxia.
    B) hypovolemia.
    C) neurogenic shock.
    D) B and C only.
    E) all of the above.
19. The paramedic might elect to administer:
    A) Levophed at 2.5 mcg/min and titrate as required for an ideal MAP of 75.
    B) Levophed at 0.5 mcg/min and titrate as required for a maximum MAP of 60.
    C) Dopamine 2.5 mcg/kg/min and titrate to obtain a BP of 100 systolic and titrate prn.
    D) A or C.
20. The patient is complaining of chest pain but is more just uncomfortable. You might elect to administer:
    A) Morphine 1 – 2 mg slow IVP.
    B) Fentanyl 25 – 50 mcg slow IVP.
    C) Demerol 100 mg IVP.
    D) A and B.
    E) All of the above.
21. The patient’s breathing gradually becomes more laboured. This can be from:
    A) Flail chest complications.
    B) Pneumothorax.
    C) Decreased diaphragmatic function.
    D) All of the above.
22. The patient’s BP is still lower than you would like, despite your initial therapies. You can next:
    A) administer a second pressor.
    B) re-evaluate the patient and look for additional bleeding sources.
    C) rebolus the patient with a 20 ml/kg of RL or NS.
    D) increase your initial pressor agent.
    E) C and D.
23. Despite your best intentions, the BP starts to decrease now. The patient’s heart rate is still low in the 60s. You can now:
    A) initiate and administer a second pressor agent to assist the primary agent.
    B) re-evaluate the patient and look for additional bleeding sources.
    C) rebolus the patient with a 20 mL/kg of RL or NS.
    D) increase your initial pressor agent.
24. Your partner starts to assist the ventilations as you are en route to the local hospital. You are about five minutes from the local ER. You should:
    A) keep going and patch the receiving centre of your current situation.
    B) pull over and perform a RSS or RSI.
    C) continue to assist the ventilations and prepare your equipment in case the patient’s breathing worsens.
    D) A and C.
25. On arrival to the local ER, the attending physician would likely order:
    A) initial 12 lead.
    B) trauma labs, CK, lactate, BS and type and screen.
    C) CXR.
    D) cervical spine x-ray, pelvis x-ray and a CT of the head, chest, abdomen and pelvis.
    E) B and D only.
    F) all of the above.